Kill the queen, diagnose the case...

Getting a detailed history of a patient is like having killed the queen in the game of chess in your first move :)...


Do not underestimate the power of a DETAILED HISTORY.
Let us look at how a proper history can help in the diagnosis of the disease.

There are seven days in a week, similarly pain in seven different regions in the chest point to 17 different diagnosis.
  • Variable: If the patient is not certain about where the pain actually is, the cause could be

    Psychiatric  (depression/anxiety) or
    Musculoskeletal
    Musculoskeletal pain usually has a history of fall or physical trauma. Psychiatric illness usually has a history of psychological trauma.
  • Retrosternal: If the pain is behind the sternum, all the causes are related to heart except for Esophageal spasm (A history of Dysphagia + Dyspepsia + Globus = Esophageal spasm.) Intermittent pain varying from several minutes to hours, aggravated by eating quickly or drinking hot / cold / carbonated beverages. 


Heart related problems presenting with retrosternal chest pain include:

Angina: often with radiation to / isolated discomfort in neck, jaw, shoulders, or arms frequently on left. Pain in stable angina lasts between 2 - 10 mins elicited by physical exertion. Pain in unstable angina lasts between 10 - 20 mins and is elicited at rest.



Myocardial Infarction: Symptoms are similar to angina. Can be differentiated using the following table:


Pericarditis: Symptoms are similar to MI / angina. Pain is usually pleuritic in nature. The pain is worse during inspiration, swallowing, movement or when lying flat. It may be relieved by sitting and leaning forward.

Aortic stenosis: Pain similar to the above three disorders. Symptoms develop gradually. Classical triad of chest pain, heart failure, and syncope may be present.

  • Substernal: Could be due to 

Esophageal reflux: Accompanied with gastric symptoms.

Pulmonary hypertension: Patient might have a history of dyspnea accomoanied with generalised edema due to increase in JVP.
  • Epigastric: May be due to
Peptic ulcer disease: Pain may occur between meals or at night. Accompanying symptoms include bloating, heartburn, nausea, vomiting or dark stools.

Gallbladder disease: This is a topic in itself. So, I think its ok to skip this ;)...
  • Anterior chest pain may be due to Aortic dissection.
  • Lateral: Points towards lungs.

Pulmonary embolism: The classic triad is pleuritic chest pain, shortness of breath, and hypoxia.

Pleuritis: The pain (sharp and localized) may increase in intensity by coughing, sneezing, deep inspiration or movement.

Pnemonia: History of exposure to infection and risk factors leading to aspiration.

Pneumothorax: Tricky tricky to suspect with just the history.
  • Dermatomal pain distribution could be due to herpes zoster.
Please note that these are typical ways the specific diseases can present themselves. In a clinical setting, one must pay attention to where the patient points to the pain rather than what he/she says. Atypical presentations happen all the time. 

Additionally, these features help us to be prepared to hit the bull's eye, actually hitting it is after you have run the tests and have proof that the particular disease exists.

If you are having trouble memorizing any particular topic in medicine, please do let me know by commenting below. I shall post an article to minimize your boredom in any possible way I can :)

Keep smiling and have a great day!

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